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Patient Safety and Quality Improvement What, Why and How Can We Teach It?

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Patient Safety and Quality Improvement What, Why and How Can We Teach It? Another Example of a PDSA: Outpatient Medicine PLAN: Identify a quality measure to target i ... – PowerPoint PPT presentation

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Title: Patient Safety and Quality Improvement What, Why and How Can We Teach It?


1
Patient Safety and Quality ImprovementWhat, Why
and How Can We Teach It?
2
ACGME Requirements
  • Practice-based Learning and Improvement
    Residents must demonstrate the ability to
    investigate and evaluate their care of patients,
    to appraise and assimilate scientific evidence,
    and to continuously improve patient care based on
    constant self-evaluation and life-long learning.
  • identify strengths, deficiencies, and limits in
    ones knowledge and expertise
  • set learning and improvement goals
  • identify and perform appropriate learning
    activities
  • systematically analyze practice using quality
    improvement methods, and implement changes with
    the goal of practice improvement
  • incorporate formative evaluation feedback into
    daily practice
  • locate, appraise, and assimilate evidence from
    scientific studies related to their patients
    health problems use information technology to
    optimize learning
  • participate in the education of patients,
    families, students, residents and other health
    professionals.
  • Systems-based Practice Residents must
    demonstrate an awareness of and responsiveness to
    the larger context and system of health care, as
    well as the ability to call effectively on other
    resources in the system to provide optimal health
    care.
  • work effectively in various health care delivery
    settings and systems relevant to their clinical
    specialty
  • coordinate patient care within the health care
    system relevant to their clinical specialty
  • incorporate considerations of cost awareness and
    risk-benefit analysis in patient and/or
    population-based care as appropriate
  • advocate for quality patient care and optimal
    patient care systems
  • work in interprofessional teams to enhance
    patient safety and improve patient care quality
  • participate in identifying system errors and
    implementing potential systems solutions.

3
So far, what do we have?
  • Teachers
  • VA Chief Resident(s) for Patient Safety and
    Quality Improvement
  • Hospitalists (VA) including Assistant Chief for
    Patient Safety and QI
  • Primary Care (VA, USF and 30th St)
  • Simulation Center
  • Dr Fabri
  • Learners
  • Internal Medicine Residents- elective and ward
    months, outpatient block
  • Medical Students- 3rd year internal medicine
    rotation, 4th year elective, AI
  • Occupational Medicine Residents
  • VA Nursing Staff

4
Outline
  • Patient Safety Principles/Activities
  • Swiss Cheese Model
  • Root Cause Analyses
  • Human Factors Engineering
  • Quality Improvement Tools
  • Flow Chart
  • Fishbone
  • Plan-Do-Study-Act
  • Quality Improvement Initiatives
  • Examples of Plan-Do-Study-Act Cycles
  • Conclusion
  • Logistics
  • Goals for the Future
  • Resources

5
Highly publicized Errors in Medicine- Normal
Accidents?
Wachter, R. M. (2008). Understanding patient
safety. New York, McGraw-Hill Medical.
6
Patient Safety
  • 1991- Harvard Medical Practice Study, NEJM
  • Reviewed gt30,000 medical charts
  • Adverse event was defined as injury that was
    caused by medical management (rather than the
    underlying disease) and that prolonged the
    hospitalization, produced a disability at the
    time of discharge or both.
  • 4 of admissions were injured
  • 13.6 of these adverse events led to death
  • gt50 were preventable (although lots of
    disagreement on this)
  • Brennan, T. A., L. L. Leape, et al. (1991).
    "Incidence of adverse events and negligence in
    hospitalized patients. Results of the Harvard
    Medical Practice Study I." N Engl J Med 324(6)
    370-376.
  • 1999/2000- Institute of Medicine report To Err
    is Human Building a Safer Health System
  • Estimated 44,000-98,000 Americans die each year
    from medical mistakes
  • 50 of these deaths were counted as not
    preventable
  • Deaths due to preventable adverse events were
    greater than MVA, breast cancer or AIDS
  • Equal to a jumbo jet crashing every day
  • Kohn, L. T., J. Corrigan, et al. (2000). To err
    is human building a safer health system.
    Washington, D.C., National Academy Press.

7
Patient Safety Principles and Activities
  • Swiss Cheese Model
  • Tracers
  • Root Cause Analyses
  • Mock- RCA
  • Human Factors Engineering
  • HFE workshops

8
Swiss Cheese Model
  • Need to focus on the root causes not just the
    sharp end of the error

Culture of Low Expectations
No procedural ID protocol
Production Pressures
Steep Authority Gradients
Reason, J. T. (1990). Human error. Cambridge
England New York, Cambridge University Press.
9
Activity Tracers
  • Examine common hospital processes with high
    impact on patient safety and quality of care,
    identify vulnerabilities and safeguards
  • MRI Tracer
  • Pharmacy Tracer
  • Thoracentesis Tracer
  • GI consult Tracer
  • Identify layers of cheese
  • Identify holes in the cheese

10
How do we analyze these adverse events?
  • Root Cause Analyses
  • What happened, why did it happen, what can be
    done?
  • Triggered from actual events and close calls with
    severe potential

11
Activity Mock RCA
12
4 Basic Steps in an RCA
  • 1) Identify the Problem
  • 2) Event Flow Chart
  • 3) Cause and Effect Diagram
  • 4) Develop Solutions or Actions
  • Strong- architectural/physical plant changes, new
    devise, engineering control or interlock, remove
    unnecessary steps
  • Intermediate- increase staffing/decrease in
    workload, software enhancement modifications,
    checklists
  • Weak- double checks, warning and labels, new
    procedure memorandum, training

13
What is Human Factors Engineering?
  • Designing systems devices, software and tools to
    fit human capabilities and limitations
  • Minimize error and optimize safety
  • Using established methods to gather unique
    information about
  • Hidden needs of the end-user
  • Unexpected interactions between the system and
    the user
  • Taking advantage of knowledge bases about human
    system interaction

14
Human Factors Engineering
VS.
At one point, the pulmonologist tried to put a
mask over Steve Jobs face when he was deeply
sedated. Jobs ripped it off and mumbled that he
hated the design and refused to wear it. Though
barely able to speak, he ordered them to bring
five different options for the mask and he would
pick a design he likedHe also hated the oxygen
monitor they put on his fingers. He told them it
was ugly and too complex. - New Yorker, Nov
14th
15
Activity HFE Workshop
  • Identify and understand how human strengths and
    weaknesses affect system design, interact with
    the environment and contribute to errors
  • - Glucometer
  • - Insulin Pen
  • - Spiriva
  • - Thoracentesis Kit
  • - Venti-masks
  • - Suction on code cart
  • - Ideas?
  • Identify weak/intermediate/strong actions

Better
Make sure to use the correct color Adaptor!?
16
Epidemiology of Quality Problems
  • 1987 Wennberg et al compared New Haven and
    Boston university hospitals
  • In 1982 expenditures per head for inpatient care
    were 451 in New haven and 889 in Boston
  • Found widespread deviations from best practices
  • Wennberg, J. E., J. L. Freeman, et al. (1987).
    "Are hospital services rationed in New Haven or
    over-utilised in Boston?" Lancet 1(8543)
    1185-1189.
  • Many studies since have demonstrated large
    variations in quality of care based on race,
    income and gender ( healthcare disparities)
  • 2003 McGlynn et al evaluated 12 metropolitan
    areas in the US, looked at performance on 439
    indicators of quality of care for 30 acute and
    chronic conditions as well as preventative care
  • 54.9 of patients received recommended care
  • McGlynn et al. The Quality of Health Care
    Delivered to Adults in the United States. NEJM
    2003 348 2635-45

Question how can doctors and hospitals be
practicing high quality, evidence-based medicine
yet have such stunningly different approaches to
the same problem?
17
What is Quality?
  • In 2001, IOM report Crossing the Quality Chasm
    defined 6 aims for a quality healthcare system
  • Patient safety
  • Patient-centeredness
  • Effectiveness
  • Efficiency
  • Timeliness
  • Equity
  • Quality is not just delivery of EBM, its much
    broader
  • Lean Maximizing value-added processes,
    eliminating waste, from the perspective of the
    end user (the PATIENT)
  • Six Sigma Remove defects, reduce variability

18
QI Tools Process Flow Diagrams
  • Graphic representation of the sequence of steps
    in a process
  • Often, one member of the process is not aware of
    what the other members are doing
  • Stay as high as possible, for as long as possible
    (the Woodstock rule)

19
Sample Flow Chart
20
What is an Ishikawa Diagram
  • Developed by Ishikawa in Kawasaki Shipyards
  • Made famous when used in the development of the
    Mazda Miata
  • AKA Fishbone diagram
  • Brainstorming Tool
  • Tool for uncovering and describing factors that
    influence an outcome
  • 3 steps
  • Identify the problem
  • - A concise problem statement
  • - i.e. Long Wait times in Clinic
  • 2. Create headers for the fish skeleton
  • - Need to be mutually exclusive and
    comprehensive
  • - i.e. People, Policy, Methods, Materials, Other
  • 3. Investigate each of the headers for more
    concrete examples
  • - i.e. understaffing at the pharmacy would fall
    under Man Power

21
Fishbone Example Long Wait Times in Primary Care
Clinic
Policy
People
HIPAA limits abilities of front desk personel
Nursing understaffed
Each physician likes things done differently
Allscripts communication rather than verbal
Long wait times in walk-in clinic
Redundancy- pts filling out same forms and
questions multiple times
Not enough exam rooms
Too many steps in the process- precheckin,
checkin, nursing intake etc..
Outdated new patient questionnaires
Methods
Materials
22
Examples of PDSAs.
Set objective Ask questions Make predictions Plan
how to answer Collect data
What changes for next cycle? Can the change be
implemented
PLAN
ACT
DO
STUDY
Carry out the plan Collect the data Begin
analysis of the data
Complete the analysis Compare data to
predictions Summarize what was learned
23
PLAN Project Charter
  • Problem Statement There are discrepancies
    between physician MRI screening questionnaires
    and MRI tech screening questionnaires
  • Primary Metric Mean of discrepancies per chart
  • Project Goals/Objectives Reduce mean of
    discrepancies per chart by 70 and increase the
    likelihood of a single chart making it through
    the process without a discrepancy
  • Scope Inpatients receiving MRIs Monday-Friday
  • Team
  • Champion Dr. Lezama
  • Process Owner Dr. Joseph Parise
  • Members Dr. Emily Lorch, Dr. Alex Reiss
    (Hospitalist Chief) Carolyn Eubanks (MRI tech
    supervisor), Gwen Patterson (MRI tech), MRI
    clerk, Lynn Martinez (CPRS)
  • What is the impact to
  • Customers improved MRI safety, decreased of
    redundant forms
  • Company improved MRI safety, improved efficiency

24
PLAN Process Mapping
Process Level 1
Process Level 2
25
PLAN Fishbone Diagram
Methods
People
Staffing issues- not enough techs
Possible to bypass form

Lack of knowledge
Discrepancies between MRI forms
Not windows compatible
Least experienced on the team
Not enough computers
Redundancy
Pt sedated by the time they get to MRI
Too many questions
Not available in paper form
Limited resident hours
Materials
Policy
26
PLAN 35 of the MRI forms had at least 1
discrepancy.
80 of the defects are in 6 fields welding,
joint, back/joint surgery, contrast
allergy, Kidney or liver disease, stents
27
DO Old Form
28
DO New Form
29
DO Educational Component
  • C
  • A
  • N
  • C
  • E
  • L

Cochlear implant
M R I
Morbid obesity
Aneurysm clip
Renal insufficiency
iNfusion pump
Insane
Cardiac pacemaker
Eye metal
Limb prosthesis
30
STUDY Binomial Analysis
  • Prior to the changes 35 of charts had at least 1
    discrepancy between the tech form and the MD form
  • Following our interventions, 3 of the charts had
    at least 1 discrepancy

31
Study Fischers Exact
  • Test and CI for Two Proportions
  • Sample X N Sample p
  • 1 35 100 0.350000
  • 2 3 30 0.100000
  • Difference p (1) - p (2)
  • Estimate for difference 0.25
  • 95 CI for difference (0.107649, 0.392351)
  • Test for difference 0 (vs not 0) Z 3.44
    P-Value 0.001
  • Fisher's exact test P-Value 0.011

32
Plan for Control Chart
Week No. of Defects No. of MRIs week 1 2
100 week 2 3 83 week 3 4 90 week 4 1
101 week 5 2 80 week 6 1 90
33
Another Example of a PDSA Inpatient Medicine
  • PLAN Thoracentesis samples sent in wrong
    tube
  • - Trace process from inpatient medicine floors,
    Interventional Radiology
  • - Fishbone diagram- pH and CBC were primary
    problems (consistent with paretos law)
  • DO Modify the Medicine Order Set
  • STUDY Following the intervention review what
    of thoracentesis tubes were sent incorrectly
  • ACT Educate IR about our new order set
  • If intervention doesnt work, how
    can we modify it

34
Another Example of a PDSAOutpatient Medicine
  • PLAN Identify a quality measure to target
  • i.e. documentation of goals of care, flu shots,
    colonoscopy screening
  • Each resident reviews their current
    processes and success
    rate with regard to the measure
  • What of patients have appropriate documentation
  • What are some barriers to meeting this measure
  • May need flow diagram, fishbone, FMEA
  • DO Develop an intervention (or action)-
  • Resident or staff education
  • Make forms more available
  • EMR modifications
  • STUDY Following the intervention review what
    of patients have appropriate
    documentation
  • ACT If intervention works, spread the
    word!
  • If intervention doesnt work, how
    can we modify it

35
Logistics
  • Initiative needs to come from the TOP
  • Need to appoint a QI/PS team leader
  • Allocate time- should start with protected time
    for both the attendings and the residents
  • Suggestions
  • Noon-conference
  • Morning report
  • Rounds
  • Outpatient block
  • Orientation
  • Part didactics but mostly active learning
  • Evaluation and feedback are important so that it
    seems like a real part of the curriculum

36
Goals for the Future
  • Other specialties and disciplines surgery,
    OB/GYN, psychiatry, dermatology, nursing etc..
  • Teach the teacher- dry run of our SGIM workshop
    A Toolbox for Teaching Patient Safety
  • Integration into orientation for both MS III and
    PGY1s
  • Integration into basic clinical months (rather
    than isolated electives)
  • Collaboration with other departments here at USF
    psychology, engineering, public health
  • Collaboration with other universities

37
Resources
  • Patient Safety
  • Wachter, R. M. (2012). Understanding patient
    safety. New York, McGraw Hill Medical.
  • Reason, J. T. (1997). Managing the risks of
    organizational accidents. Aldershot, Hants,
    England Brookfield, Vt., USA, Ashgate.
  • National Patient Safety Center
    http//www.patientsafety.gov/curriculum/index.html
    (Dr. James Bagian)
  • Agency for HealthCare Research and Quality
    http//webmm.ahrq.gov/
  • Dr. Fabris Course here at USF Patient Safety
    and Human Error
  • Quality Improvement
  • Nolan, K. M. and M. W. Schall (2007). Spreading
    improvement across your health care organization.
    Oak Brook, Ill. Cambridge, MA, Joint Commission
    Resources Institute for Healthcare Improvement.
  • Berwick, D. M., A. B. Godfrey, et al. (1990).
    Curing health care new strategies for quality
    improvement a report on the National
    Demonstration Project on Quality Improvement in
    Health Care. San Francisco, Jossey-Bass.
  • Ogrinc, G., L. A. Headrick, et al. (2004).
    "Teaching and assessing resident competence in
    practice-based learning and improvement." J Gen
    Intern Med 19(5 Pt 2) 496-500.
  • American Society for Quality http//asq.org/confe
    rences/six-sigma/
  • Dr. Fabri
  • National Meetings
  • SGIM- Patient Safety/QI Workshop, Precourse
    Orlando May 5-9th
  • Society for Hospitalist Medicine
  • Institute for HealthCare Improvement
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